Early surgical treatment of closed reduction and internal fixation for a 30-day old intertrochanteric fracture with hemiplegia after acute stroke: A case report

Rationale: Currently, there are no clear guidelines to determine whether and when to perform surgical hip repair in patients with acute stroke and hip fracture. Patient concerns: In this case report, we report a case of 75-year-old woman admitted with left hip pain and limited mobility for 1 month. Diagnoses: Patient had a history of acute cerebral infarction 42 days ago, and diagnosed with a left intertrochanteric fracture at another hospital 30 days ago. Intervention: Patient was treated with closed reduction and internal fixation with proximal femoral nail anti-rotation. Outcomes: At 2-year follow-up, the patient’s basic function was restored. The fracture healed well, and the Harris hip score was 75. Lessons: Without consistent guidelines, individualized treatment strategies including surgical methods and timing of surgery should be made to weigh the risks and benefits for patients with acute stroke and intertrochanteric fractures.


Introduction
Hip fractures are a significant post-stroke complication. [1,2] The incidence of hip fracture in stroke patients with hemiplegia is 2 to 4 times higher than that of healthy people. [3][4][5][6][7] Paradoxically, hip fractures in elderly also increase stroke risk, [8] and needing early surgical treatment to reduce morbidity and mortality. [9] Prior studies have shown that hemiplegia after acute stroke combined with hip fracture leads to worse neurological recovery, prolonged hospitalization period, increased complications, decreased patient prognosis, and increased 30-day and one-year mortalities. [3,4] The surgical treatment goals of intertrochanteric fractures were fracture stabilization, early patient mobilization, and restoring to previous level of independence and function. [10] The mainstream treatment is internal fixation (including intramedullary and extramedullary), and hip arthroplasty has also been reported. [11][12][13] However, there is no accepted surgical procedure for old intertrochanteric fractures. At the same time, acute cerebral infarction is a relative contraindication to hip reconstructive surgery, therefore, most of these patients cannot undergo surgical treatment. [4] In general, elective surgery after acute stroke is best delayed by 2 weeks, preferably 6 weeks. However, there are no clear guidelines to determine whether Written informed consent was obtained from the patient for publication of this article.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethical approval from the institutional review board was not required for this study. Medicine and when to perform surgical hip repair in patients with acute stroke and hip fracture.
We report a case of an old femoral intertrochanteric fracture with hemiplegia after acute stroke, treated with closed reduction and internal fixation (CRIF) with proximal femoral nail anti-rotation (PFNA).

Case presentation
Informed consent was obtained from the patient for publication of this case report details.
A 75-year-old woman was admitted with left hip pain and limited mobility for 1 month. She had a history of acute cerebral infarction 42 days ago (Fig. 1), and tripped during rehabilitation    exercise 30 days ago. She was diagnosed with a left intertrochanteric fracture at another hospital, but the operation was postponed due to acute cerebral infarction. The patient's left lower limb showed obvious adduction and external rotation deformity ( Fig. 2A and B). The skin of the left hip appeared skin rash due to external use of Chinese herbs (Fig. 2C), and there was a third-degree pressure sores on the sacral tail skin (Fig. 2D). The muscle strength was grade I of left lower limb, and grade III of left upper limb. Neurological function scores were evaluated preoperative, the National Institutes of Health stroke scale [14] was 7, and the activity daily living was heavily dependent and the Barthel index 14,15] was 30.
Radiographs and computed tomography identified a type I, group IV intertrochanteric fracture according to Evans classification (Fig. 3). The Dual-energy X-ray absorptiometry of the right hip was examined, and the T-score was −3.9.
After successful epidural anesthesia, the patient was placed in the supine position. The partially bone union was simply re-fractured using closed reduction manipulation, and the left lower limb was maintained traction and rotated inward, then c-arm fluoroscopy was performed. When the fracture had basically reached anatomical reduction, the patient underwent CRIF with percutaneous PFNA on traction bed (Fig. 4).
Cefuroxime (1.5 g intravenously twice a day) was given 24 hours perioperative to prevent infection. Low molecular weight heparin (1500 μL subcutaneous injection once per day) was given to prevent deep vein thrombosis, and was bridged with aspirin (0.1 g orally, once a day) 5 weeks after surgery. Atorvastatin (20 mg orally, once a day) was used to prevent recurrence of stroke. Anti-osteoporosis therapy was also used.
The patient was encouraged to move early on the bed with endurable pain. Postoperative rehabilitation treatment was continued twice a day, including physical therapy, aerobic training and physical agents therapy. Specific rehabilitation training measures need to be evaluated and adjusted according to the actual situation of the patient. Table 1 lists the details of rehabilitation methods. Acupuncture was also performed once a day.
The pressure ulcer healed 2 weeks after operation. At 12 weeks postoperatively, the fracture healed radiographically and the patient was able to stand on support or with the aid of a walker. At 2-year follow-up, the muscle strength was grade IV of left lower limb, and grade V of left upper limb. The National Institutes of Health stroke scale was 0, and the activity daily living was independent and the Barthel index was 80. The fracture healed well, and the Harris hip score was 75 (Figs. 5 and 6). Table 1 The details of the patient's rehabilitation methods.

Discussion
Although acute cerebral infarction is a relative contraindication to surgery, a small sample study (11 cases) in which the patients and family members requested and insisted on hip reconstructive surgery has reported that surgical treatment can improve the prognosis of patients with acute cerebral infarction. [4] However, the study did not address the timing of surgery or the surgical treatment method of hip reconstruction. A case of intertrochanteric fracture and acute stroke, focusing on individual factors to reduce postoperative complications and recurrent stroke rate by a multidisciplinary team, treated with PFNA has been reported. [16] In our case, the 30-day intertrochanteric fracture had local callus growth at the fracture end on images, which may due to brain injury. [17] Meanwhile, acute post-stroke hemiplegia, pressure sores, and drug eruption of the hip make treatment more difficult. We prepared 2 surgical options. According to the healing process of the 30-day intertrochanteric fracture, the fracture ends have been connected by cartilage callus, and hard callus gradually appeared. At this point, closed reduction was still possible. Intraoperative fluoroscopy after closed reduction also confirmed our judgment. If closed reduction fails, hip arthroplasty would be chosen.
CRIF with PFNA has 3 advantages. First, it corrected the hip deformity and relieved the pain. Second, compared with hip arthroplasty, the operation is less traumatic and conducive to postoperative rehabilitation. Third, revision hip arthroplasty is still available after failed fixation. [18] Hemiplegia, pressure sores, and drug eruption of the hip may increase the risk of dislocation and infection after hip arthroplasty, therefore, only considered as an alternative to the failure of closed reduction. At the same time, total hip arthroplasty for old intertrochanteric fracture is more difficult procedure than for osteonecrosis or osteoarthritis.
In conclusion, without consistent guidelines, individualized treatment strategies including surgical methods and timing of surgery should be made to weigh the risks and benefits for patients with acute stroke and intertrochanteric fractures.